HospitalInspections.org

Based on review of medical records, Medical Staff Bylaws, policy and procedures and staff interviews, it was determined that the facility failed to ensure that an individual received an appropriate, ongoing medical screening examination within the capabilities of the hospital's emergency department for one (P#1) of 20 sampled patients. Specifically, P#1 presented to the facility's emergency department (ED) with a chief complaint of leg pain. P#1 had a history of psychiatric conditions and was transferred via ambulance to a psychiatric facility on 5/14/25 at 8:00 p.m. The facility failed to ensure that P#1's medical records were transferred with P#1. P#1 was returned to the ED on 5/15/25 at 12:15 a.m. The facility failed to conduct an MSE after P#1 was returned to the ED. In addition, P#1 was discharged to home on 5/16/25 despite recommendations from a psychiatry consultant to transfer P#1 to an inpatient psychiatric facility for stabilization.

Findings included:

Cross refer to A-2406 as it relates to the facility's failure to provide a Medical Screening Examination for P#1 after she was transported back to the ED.

Cross refer to A-2407 as it relates to the facility's failure to effect an appropriate disposition for P#1.

Cross refer to A-2409 as it relates to the facility's failure to ensure that P#1's medical records were transferred to the receiving facility.

Based on review of medical records, Medical Staff Bylaws, policy and procedures and staff interviews, it was determined that the facility failed to ensure that one (P#1) out of 20 sampled patients received an appropriate medical screening examination within the facility's capacity and capability to determine whether an emergency medical condition existed. Specifically, the facility failed to discharge and readmit P#1 after she (P#1) was transferred out of the ED and was then returned to the ED after approximately four hours, which resulted in P#1 not receiving a medical screening examination after return.

Findings include:

A review of P#1's medical record revealed she arrived at the ED on 5/13/25 at 5:14 a.m. with a chief complaint of leg pain and bilateral foot pain. The triage nurse documented that P#1 barely answered questions in triage and that P#1 denied suicidal or homicidal ideations. P#1 reported that she was eight weeks pregnant. An MSE was initiated by medical doctor (MD) AA on 5/13/25 at 6:30 a.m.

An order for a psychiatric consult was entered at 1:27 p.m. P#1 was evaluated by a Licensed Professional Counselor (LPC) with Psychiatry at 2:50 p.m. who recommended transfer to an inpatient psychiatric facility with a diagnostic impression of schizophrenia.

Continued review of the record revealed that at 1:29 p.m. P#1 had been accepted for transfer to Facility#2. At 4:45 p.m. P#1's physician spoke with her sister on the phone and updated her on plans for transfer to Facility#2. At 5:39 p.m. report was given to personnel at Facility#2 by P#1's nurse. At 8:15 p.m. Emergency Medical Services (EMS) arrived to transport P#1 to Facility #2.

A further review of P#1's chart revealed on 5/15/25 at 12:15 a.m. P#1 was brought back to the facility by EMS after Facility#2 declined to accept P#1 stating they had no knowledge of P#1 being accepted there. P#1 was placed back in an ED room upon arriving back from Facility#2. On 5/15/25 at 7:34 a.m. a consult for psychiatry was ordered.

A review of psychiatry progress notes dated 5/15/25 at 2:30 p.m. revealed:
Impression:
Schizophrenia
Polysubstance use disorder
History of Anxiety
Psychosocial stressors
Plan, Recommendations, and Comments:
1. Recommendation to maintain 1013 (involuntary hold).
2. Recommendation to continue to follow-up with inpatient psychiatric hospitalization for continued stabilization
3. Recommendation to continue to assess mood, thoughts, behavior, sleep, appetite.
4. Recommendation to hold medication for now.
5. Psychiatry will continue to follow on an as needed basis and make recommendations. Final disposition to be determined by Primary team as we are a consult team.

A review of the 'Medical Staff Bylaws and Rules and Regulations' approved 3/21/23 revealed that: Article XI Emergency Services
11.A General Emergency services and care will be provided to any person who comes to the emergency department, as that term is defined in the EMTALA regulations, whenever there are appropriate facilities and qualified personnel available to provide such services or care. Such emergency services and care will be provided without regard to the patient's insurance status, economic status, or ability to pay for medical services.
11.B Medical Screening Examinations
(1) Medical screening examinations, within the capability of the Hospital, will be performed on all individuals who come to the Hospital requesting examination or treatment to determine the presence of an emergency medical condition. Qualified Medical Personnel ("QMP ") who can perform medical screening examinations within applicable Hospital policies and procedures are defined as: (a) Emergency Department: (i) members of the Medical Staff with clinical privileges in Emergency Medicine; (ii) other Active Staff members; and (iii) appropriately credentialed Advanced Practice Professionals.
(2) The results of the medical screening examination must be documented by the end of the next calendar day.

A review of the facility's policy titled "Emergency Medical Treatment and Active Labor (EMTALA)", PolicyStat ID 18039982, last reviewed 4/24/25, revealed the purpose was to ensure that the facility's dedicated emergency department would comply with the Emergency Medical Treatment and Labor Act (EMTALA) and all Federal regulations and interpretive guidelines promulgated thereunder, would provide appropriate medical screening and necessary stabilizing treatment to anyone seeking emergency care. The facility's Emergency Department would ensure that all individuals who requested an examination for a possible Emergency Medical Condition (EMC), including women in Labor, would be provided with an appropriate Medical Screening Examination (MSE) and Stabilizing treatment prior to discharge or transfer. MSEs and Stabilizing treatment would be provided regardless of an individual's ability to pay, age, race, sex, color, religion, national origin, citizenship, pre-existing medical condition, physical or mental handicap or insurance status, whether the individual was in the hospital's DED or elsewhere on Hospital Property.

An interview was conducted in the conference room on 6/3/25 at 11:19 a.m. with Medical Doctor (MD) AA. MD AA recalled that P#1 came into the ED barefooted and ambulatory. MD AA stated that the triage nurse requested that she come to assess P#1 as she (P#1) exhibited odd behavior. During a review of the electronic medical record, MD AA learned that P#1 was pregnant. MD AA recalled that P#1 seemed like she was under the influence of something. MD AA stated P#1 slept a lot the first day she was in the ED. MD AA stated she talked to P#1's sister twice during the encounter to update, get the history and a list of medications that P#1 had been prescribed. P#1 was unable to provide any history. MD AA learned from P#1's sister that P#1 had recently been discharged from psychiatric inpatient treatment after a two month stay. P#1's sister also informed MD AA that she (P#1) was supposed to be living with her (sister) but had been missing for five days. MD AA stated P#1's sister did not mention having Medical Power of Attorney (POA) over P#1. MD AA further stated that she ordered for P#1 to have placed her on a 1013. During P#1's first visit MD AA performed a Medical Screening Examination on P#1 with a medical workup and ultrasound and fetal heart tones. MD AA stated that P#1 appeared to be around 20 weeks pregnant. MD AA recalled that on P#1's day two in the ED, an inpatient facility had still not been found. MD AA stated when she left her shift around 8pm on 5/15/25 Emergency Medical Services (EMS) was on the way to pick up P#1 to take her to Facility#2. MD AA stated that was the last contact she had with P#1. MD AA stated she was not sure what the protocol was if a patient was returned to the ED regarding the medical record. MD AA stated she would talk to her medical director and see what to do if the patient returned. MD AA stated physicians must do a face to face every four hours for patients who are on 1013. Face to face involves seeing the patient in person.

An interview was conducted in the conference room on 6/3/25 at 11:32 a.m. with Registered Nurse (RN) BB. RN BB stated she was the nurse who discharged P#1 from the ED on 5/16/25. RN BB stated it was time to renew the 1013. RN BB stated MD GG, and his scribe went in to reassess P#1 and he (MD GG) felt like P#1 could go home. RN BB stated P#1 wanted to go home. P#1 was calm and cooperative. RN BB stated she did not talk to P#1's sister. RN BB stated that she gave P#1 her belongings that had been locked up and P#1 left ambulatory out of the ED.

An interview was conducted in the conference room on 6/3/25 at 1:30 p.m. with ED Nursing Director (ND) DD. ND DD stated she did not have any contact with P#1. ND DD stated that a 1013 order was good for 72 hours. If the medical provider determined that the patient could go home, then the patient was discharged. ND DD stated that if a patient was transferred to another facility, the patient was discharged out of the facility. ND DD stated if a patient returned to the facility, the patient was re-admitted. ND DD also stated when a patient was readmitted to the ED, the provider would do another MSE. ND DD stated that a face to face was not an MSE.

An interview was conducted with Medical Doctor (MD) GG via telephone on 6/3/25 at 3:30 p.m. MD GG stated that when P#1 returned to the ED from Facility #2, P#1 should have had a new encounter with a new MSE conducted. MD GG further stated that if a patient had a medical POA, it was activated only when the patient becomes incapacitated and not able to make decisions on her own. MD GG stated P#1's sister was not her legal guardian.

An interview was conducted with the Medical Director (MD) HH of the Emergency Department on 6/3/25 at 2:50 p.m. via telephone. MD HH stated that his staff did not notify him when P#1 was in the ED or after being returned from Facility#2. MD HH stated when a patient leaves the ED and returns for any reason, a new chart or encounter would be initiated. MD HH stated that the process would start all over including a new MSE. MD HH stated that a face to face was not considered an MSE.

An interview was conducted via telephone on 6/3/25 at 3:38 p.m. with RN II. RN II recalled that she was assigned P#1 for a short time prior to EMS transport to Facility #2. RN II stated that if a patient was returned to the ED after being transferred out, she was unsure how to handle the paperwork concerning readmitting the patient to the ED.

An interview was conducted via telephone on 6/3/25 at 4:07 p.m. with RN JJ. RN JJ stated she recalled P#1. P#1 was gone from the ED approximately four hours before returning after Facility #2 declined to accept her. RN JJ stated the person at Facility#2 said they had rescinded the acceptance due to P#1's high risk pregnancy. RN JJ stated P#1 was already discharged from the ED and requested that the chart be repopulated back into the ED log. RN JJ stated the physician saw P#1 after she (P#1) returned to the ED. RN JJ stated that she contacted the behavioral health intake to let them know P#1 had returned so they could try to get her placed under a 1013.

Based on review of medical records, policy and procedures and interviews with staff, it was determined that the facility failed to ensure an appropriate disposition when P#1 was discharged from the facility on 5/16/25 at 9:36 a.m. despite recommendations for inpatient psychiatric treatment from a psychiatric consultation.

Findings included:

A review of P#1's medical record revealed a progress note by psychiatry dated 5/15/25 at 2:30 p.m. that P#1 had impaired attention, concentration and memory with poor insight of her current health needs. P#1's reliability was uncertain, and she was noted to be paranoid and delusional. P#1 was determined to be high risk for suicide and violence at the time of the examination. The consultants' recommendations were to maintain the involuntary hold; inpatient psychiatric hospitalization for stabilization; and continue to assess P#1's mood, thoughts, behavior, sleep and appetite.

A review of nursing notes revealed that P#1 exhibited paranoid delusions and impaired judgement on 5/15/25 at 1:52 p.m. A physician note on 5/15/25 at 4:00 p.m. revealed that a referral for inpatient placement at another facility was made. All facility's contacted thus far had declined to accept P#1.

A review of physician progress notes on 5/15/25 at 6:14 p.m. revealed that an inpatient transfer was still being pursued. P#1's involuntary hold remained active, and the patient had a sitter for one-to-one observation.

On 5/16/25, a physician note at 9:00 a.m. revealed that P#1 denied suicidal or homicidal ideations, agreed to stop using drugs and was stable for discharge. The record failed to reveal a psychiatric or neurological examination by the physician. The involuntary hold was rescinded, and P#1 was discharged at 9:36 a.m. without family contact.

A review of the facility's policy titled "Authorizing Transport to Emergency Receiving Facility for Mental Health and/or Addictive Diseases Policy", PolicyStat ID 15342117, last reviewed 3/6/24 revealed that patients who accessed care at the facility who required psychiatric treatment would be managed through referral and transferred to a psychiatric receiving facility and/or managed through consultative psychiatric services on a temporary basis. Patients who demonstrated behaviors suggestive of risk for suicide, risk of harm to others, substance abuse / addiction, or other behaviors that posed a serious and significant safety risk to the patient, staff, other patients, visitors and/or the community would be assessed and would have a Form 1013 or Form 2013 executed to effectuate transfer to an ERET facility. Execution of Form 1013 A Certifying Professional, who had personally examined a patient within the previous 48-hour period, would execute a Form 1013 if the following conditions* are met: The patient appeared, in the opinion of the Certifying Professional, to be a mentally ill person requiring involuntary treatment in that he/she appears to be mentally ill; AND: EITHER The patient presented a substantial risk of imminent harm to self or others as manifested by recent overt acts or recent expressed threats of violence which presented a probability of physical injury to self or other persons; OR The patient appeared to be so unable to care for his/her own physical health and safety as to create an imminently life-endangering crisis.

Upon execution of Form 1013 and pending transfer to an ERET facility, appropriate safety precautions would be implemented in accordance with this policy. *The Certifying Professional would include specific observations when completing Form 1013 that support the finding that the necessary conditions exist for issuing Form 1013. A Form 1013 would expire seven (7) days after being signed by a Certifying Professional.

If the Form 1013/2013 expired, the original form must be maintained with the patient's medical record with "Expired "written across the front of the original document. If the form expired, a note would be entered in the patient's medical record by the attending physician documenting the reasons for non-renewal.

An interview was conducted in the conference room on 6/3/25 at 11:19 a.m. with Medical Doctor (MD) AA. MD AA stated that P#1 came into the ED barefooted and ambulatory. MD AA stated she was called to triage by the triage nurse stating P#1 was not acting right. A review of the electronic medical record documented that P#1 was pregnant. MD AA stated P#1 seemed like she was under the influence of something. MD AA stated P#1 slept a lot the first day she was in the ED. MD AA further stated she ordered for P#1 be placed on a 1013. MD AA stated she performed a Medical Screening Examination on P#1 with a medical workup and ultrasound. MD AA stated she obtained fetal heart tones from P#1 and P#1 appeared to be around 20 weeks pregnant. MD AA stated the second day she saw P#1 she had still not been assigned to an inpatient facility. MD AA stated physicians must do a face to face every four hours for patients who are on 1013. Face to face involves seeing the patient in person and the sitter to see if there are any concerns.

An interview was conducted in the conference room on 6/3/25 at 11:32 a.m. with Registered Nurse (RN) BB. RN BB stated she was the nurse who discharged P#1 from the ED on 5/16/25. RN BB stated it was time to resign the 1013. RN BB stated MD GG, and his scribe went in to reassess P#1 and he (MD GG) felt like P#1 could go home. RN BB stated P#1 wanted to go home. P#1 was calm and cooperative. RN BB stated she did not talk to P#1's sister. RN BB stated she gave P#1 her belongings that had been locked up and P#1 left ambulatory out of the ED.

An interview was conducted via telephone with Nurse Practitioner (NP) EE on 6/3/25 at 2:03 p.m. NP EE stated she was familiar with P#1. NP EE stated a psychiatric consult was ordered on 5/14/25 early in the morning. NP EE stated she evaluated P#1 on 5/14/25 around 4 p.m. The evaluation was for psychosis. NP EE stated P#1 was pregnant and was delusional. NP EE further stated P#1 was positive for Cocaine and Amphetamines. NP EE stated P#1 had just recently left a psychiatric facility. NP EE stated P#1 told her that she was on injections for psychiatric medication. NP EE said P#1 informed her that she came to the ED to gets antipsychotic medication injection. NP EE stated she recommended to continue the 1013 for P#1. NP EE stated when she went to the ED the following day P#1 was still there but in a different room. NP EE asked staff members why P#1 was still there in the ED. NP EE stated she was informed by the staff that P#1 was transported to Facility#2 and Facility#1 rescinded the transport. NP EE was consulted again by the ED physician to evaluate P#1. NP EE stated she evaluated P#1 on 5/15/25 at 2:30 p.m. NP EE stated when she evaluated P#1 on 5/15.25 she was not talking to her much. NP EE was trying to determine what medications to order for P#1. NP EE stated she asked P#1 if it was okay to talk to her sister. P#1 agreed for NP EE to call her sister. NP EE spoke with the nurse taking care of P#1 and the sitter. NP EE called the P#1's sister and left a message. NP EE stated P#1's sister returned her call, and she asked her to bring P#1's medication list and the discharge summary from the last facility. They continued to look for a facility for her. NP EE stated she recommended that P#1 stay on the 1013 due to lack of medication and being pregnant. NP EE stated P#1 could not tell her about any details regarding her health and P#1 stated she did not know how she got pregnant. NP EE stated P#1 finally did admit that she used cocaine for pain relief.

An interview was conducted with Medical Doctor (MD) GG via telephone on 6/3/25 at 3:30 p.m. MD GG stated he remembered P#1. MD GG stated P#1 was pregnant and had a history of polysubstance abuse. MD GG stated P#1 placed under a 1013 while she was in the ED. MD GG stated upon review of the records P#1 never said she was suicidal or homicidal. MD GG stated P#1 was confused. MD GG stated that NP EE consulted for a psychiatric evaluation of P#1 and documented that P#1 was alert and oriented times three, but she had delusions. MD GG stated NP EE recommended to continue P#1 on 1013, but MD GG stated there was not documentation backing this. MD GG stated when he saw P#1 she had been there for over 72 hours. P#1 was cooperative and calm and never exhibited psychotic behavior. MD GG stated he interviewed P#1, and she expressed some remorse and agreed not to use drugs anymore.

Based on review of medical records, policy and procedures and interviews with staff, it was determined that the facility failed to ensure that an appropriate transfer was effected on 5/14/25 at 8:15 p.m. when P#1, a psychiatric patient was transferred to a receiving psychiatric facility. Specifically, the facility failed to ensure that a copy of P#1's medical records either accompanied the patient or was sent electronically to the receiving facility. In addition, the facility failed to ensure that a transfer certification form that included the risks and benefits of transfer was included in the medical record.

Findings included:

A review of P#1's medical record failed to reveal documentation that medical records were provided to the receiving facility at transfer on 5/15/25 at 8:15 p.m. A further review failed to reveal documentation of a transfer certification form that included the risks and benefits of transfer and signed by the Emergency Department (ED) physician.

A review of the facility's policy titled "Emergency Medical Treatment and Active Labor (EMTALA)", PolicyStat ID 18039982, last reviewed 4/24/25.
A. Appropriate Transfers. A facility would not transfer to a non-Stabilized patient unless all the following conditions had been met:
3. The facility had provided all available medical records related to the EMC (Emergency Medical Condition) for which the individual had presented, including documentation related to observation of signs or symptoms, preliminary diagnosis provided, treatment provided, result of diagnostic studies or telephonic reports of the studies and the informed written consent for transfer or certification to do so. Any other records that were not readily available at the time of transfer would be sent as soon as practicable after the transfer.

An interview was conducted in the conference room on 6/3/25 at 11:19 a.m. with Medical Doctor (MD) AA. MD AA stated when she left her shift around 8pm on 5/15/25 Emergency Medical Services (EMS) was on the way to pick her up to take her to Facility#2. MD AA stated that was the last contact she had with P#1. MD AA stated that patients are transferred out with an EMTALA form.

An interview was conducted via telephone on 6/3/25 at 3:38 pm with RN II. RN II stated she was familiar with P#1. RN II stated she was assigned to P#1 for a short time then EMS came to transport her to Facility#2 and then RN II stated she remembers the charge nurse saying P#1 was coming back to the ED. RN II stated the day shift nurse said he called report to the accepting facility.

An interview was conducted via telephone on 6/3/25 at 4:07 p.m. with RN JJ. RN JJ stated she did remember P#1. RN JJ stated she works the night shift. RN JJ stated the day shift had already given report to Facility#2, where P#1 was being transferred. RN JJ stated when EMS arrived, she reviewed the transferring paperwork. RN JJ stated it had been approximately four ish hours when the ambulance service brought P#1 back. Facility #2 denied having documentation that P#1 had been accepted at their facility. RN JJ stated she told the person that she had an accepting MD and that he had spoken to the MD there and the RN in the ED had given report to a nurse at Facility #2. RN JJ stated the person at Facility #2 said they had rescinded the acceptance due to P#1's high risk pregnancy.